That's oh-be-GUY-n, not oh-be-GIN, as some (primarily people from Texas) would like to refer to my chosen profession. Although, working in this field can sometimes cause one to develop a penchant for gin...hmmm.

Friday, August 07, 2009

Stuck, stuck....STUCK!

As my time in Whooville was drawing to a close, I found myself in a very harrowing situation. As per usual, I was extremely busy delivering all of OtherDoc's patients, as well as my own patients during his vacation. (I never understood why he wouldn't limit the number of OB patients he would take when he knew he would be gone for half the month...oh, right, all about the dolla bills, y'all.)

There was a young patient (YP) that I had seen in the office earlier that day, she had been contracting, and while she was not yet dilated, she was beginning to soften and efface. I wasn't too surprised to see her later that evening at L&D. She was extremely uncomfortable, contracting every 2-3 minutes, and had dilated to 2 cm/90% effaced. It had been a long day, so I assumed that we would get her comfortable (she was requesting an epidural) and then she could labor through the night. The day shift left and the night shift came, and sometime in the middle of her bolus for her epidural, YP began to get a little out of control....like "I'm in transition" out of control. If you've never seen it, it is kind of like that seen from the Exorcist, minus the rotating head. I checked her, and surely enough, she was 8 cm. She had gone from 2 cm to 8 cm in the space of about an hour and a half. So much for the game plan.

The patient progressed quickly from 8 cm to complete, and that, dear friends, is when the fun began. As the patient began to push, the baby began to get unhappy. The more she pushed, the more unhappy the baby became. There were persistent and prolonged, deep variable and late decelerations. After tolerating the strip as long as I could, I talked to the patient and talked to the OR. preparing for a C-section. One problem, the anesthesiologist was not in house. Just at that moment, the baby decided to express her extreme displeasure with the proceedings by dropping her heart rate. To the 60s...one minute, two minutes, reposition, oxygen, scalp stim...no response. Three minutes, four minutes, more maneuvers, still no response. The patient was pushing with all of her might, her family was a step a way from hysterical, the baby was in trouble, and there was no anesthesiologist. The vertex was just barely at +2 station, so I attempted an emergency vacuum delivery. I pulled once...no descent...I pulled twice...small descent...I cut an episiotomy and pulled one final time to no avail. We had to go to the OR, and we had to go right then, anesthesiologist or not. At that point the baby had been in the 60s for about 10 minutes. "Please don't let my baby die." were the last words I heard before we left the floor.

We ran to the OR, and I told the CRNA to put the patient to sleep, anesthesiologist or no. I remember that the staff was moving as slow as molasses, even though I had relayed the urgency of the situation. We splashed the belly with betadine, draped her, the CRNA put the patient to sleep, and I went from skin to baby in under a minute. The nurse had to push up from below, and it was difficult to elevate the head out of the incision, but, thankfully we finally got her unstuck. All 9 pounds 8 ounces of her. She was a little pale and a little floppy, but pinked up almost immediately to get Apgars of 6 and 9. She was ok. Mom was ok. The nurses and I were puddles of goo. The adrenaline surge was so strong I was shaking.

I think the anesthesiologist finally got there as I was replacing the uterus. Thank God we didn't wait for him. After the C-section was over, I repaired her episiotomy. It didn't seem quite fair to be sore both places, but she had a happy, healthy baby. I kept turning the situation over and over in my mind. How could I have changed it? What could I have done to avoid the outcome? I felt like I had failed her in so many ways. It seemed incongruous when the nurses told me how "awesome" I was, and how the family cried and hugged me after the surgery. Afterwards, both mom and baby did wonderfully well. It was better than I could have ever hoped for, and an experience that I never, ever want to repeat.

Hi! I just recently started reading your blog - I'm a NICU nurse, and I really enjoy reading about the other side of things :) We just recently had a baby in our unit with severe shoulder dystocia that ended up having to have total body cooling because of the extent of the asphyxia at birth, all because the OB delivering him didn't follow any standard procedure and made very little effort to get him out quickly. So sad.

Kudos to you for a job well done - mom and her family should be very thankful :) (And, personally, I think a healthy, living baby is worth BOTH perineal and abdominal pain - you did what you needed to do to get that baby out as fast as you could.)

I always tell patients there are worse things than a c-section - and I know that momma thanks you for both incisions - just to have a healthy baby. But, man, I do know that agony of having to go over and over that scene in your head - it's times like that when I start thinking about other careers, but realize that I'd always miss the rush and the challenge that is ob :) but really, shouldn't I have worked to be a dermatologist??

I think in this situation you made the right call. Don't beat yourself up about it! But I know if I was the doctor I'd mull it over and over and over again, too, wondering what to do differently. *HUGS* Ultimately you helped deliver a LIVE baby into the world. It could've turned out much differently.

remember me? the out-of-hospital birth midwife? yeah. Well, when you got to the prolonged 60s all I could say was "oh F**k" and I was literally on the edge of my seat.

I tell women all the time that if their worst case scenario is a c-section, they are living a great life. And if it comes to pass, they are still living a great life. and I think a lot of "you should get the heck over it" when they act like a C is the end of the owrld because they didn't get the beautiful natural out of hospital birth they imagined.

Sometimes the baby has another agenda. You did everything right. Everything. You tried to get her a vaginal birth, but not so long that she has a damaged baby. You got her the C efficiently and effectively. You are my heroine tonight, Dr. Whoo. I love docs like you, who care about it so much, but who also are so skilled and so competent and can save the day when no one else could-- especially when I couldn't.

I love reading your perspective on these things. And as an OB nurse, I can tell you, it's the most incredible feeling when you're in an emergent c/s and you meet hands with the Dr unsticking a baby from down below. 60's bpm for 10 min.....s-c-a-r-y. Not too long ago we had an apgar of 2-3-9. Talk about code brown with the staff!!!!

This stuff happens and this is why you need all your training! You did exactly what was needed. Please tell me you have 24-hour anesthesia at your new hospital. What if you hadn't had the CRNA? Can you say "c/s under local"? Good job in a very tough situation!

Another midwife perspective - sounds to me like you did all the right things! I admire your braveness and willingness to go all out. Many docs would have cut long before you did. We walk a fine line sometimes - and it's stressful ain't it!?

Your story brought back distant memories of my first son's birth. I hadn't yet fully dialated, and his heartrate dropped into the 50s and 60s....don't remember for how long, exactly, but I remember the medical staff moving SO FAST. 3 years later, I am still so amazed at how everyone worked together, and so calmly (at least it seemed that way to me...I'm sure it was different for them!) I changed positions, got O2, all to no avail - not a happy baby. Things moved like lightening after that, and I was put under general anesthesia for my son's birth. Not exactly how I planned to welcome him into the world, but so grateful for his health - after APGARs of 3 & 9.No worries: your patient will only best remember the outcome ~ a live, healthy, and happy baby. Thank you for doing what you do SO WELL!!

April, just curious for more details, because I get a mental image of a baby getting stuck and the obstetrician stepping back and twiddling his thumbs. If that's the case, then someone should be filling an incident report, at least.

Were you present at the birth? What would you consider a standard procedure for shoulder dystocia and what did the obstetrician do that you considered to be inappropriate?

If you make the call for a C/S and have a CRNA there, you might as well go straight to the OR. A CRNA should certainly be able to put a patient to sleep if need be. I hate elevating the head from above in that low of a station - my hand always trembles afterwards from exerting so much hand muscle power. Job well done!

Wow! I'm glad you did all you could and that the outcome was good. When I was trying to push out my stuck baby my doctor and no other nurses were present to help because everyone had screwed up! Even the nurse delivering my baby with only my scared husband by her side didn't do the standard maneuvers she was supposed to. Thankfully, she did yank my baby out with no damage. It was a "mild dystocia" but it scared the heck out of me! I fired my OB the next day. I'm sure that you would've been at my delivery. You sound very conscientious, Dr. Whoo. Way to go!

Sounds like you gave the mom every chance for a vaginal delivery but the baby was no longer safe. Though I would have probably had a sad time afterward as a mom, wishing I could have had the vaginal birth I wanted...I would have to recognize that some things cannot be forced and controlled. Because you had mom moving, you tried everything to get baby out, and baby had such terrible decels, that was all evidence you made the right decision. I would rather have scars on my body than a lifeless or damaged baby.